Workshop No. 1 Registration Form

Name:____________________________________________________________
     
Affiliation:_____________________________________________________
     
Address:_________________________________________________________
          
City:_______________________________ State/Province:_____________
     
Country:_______________________ Zip/Postal Code:_________________

Phone:____________________ E-mail:_______________________________

REGISTRATION FEE:

  [ ]  $50.00 US through April 6
       (Registration onsite only after April 6)
	   
  [ ]  $35.00 US dinner and speaker, April 12 [optional]
    
PAYMENT

  [ ] Check payable to Alaska Sea Grant enclosed
        
  [ ] Charge my VISA or MasterCard account

Card number: __________________________________ Expires: ________

Signature:_____________________________________

Printed Name:__________________________________

Please fax or mail form to:

Workshop Coordinator
Alaska Sea Grant College Program
PO Box 755040
Fairbanks, AK 99775-5040 USA
Fax: (907) 474-6285